Sepsis Resuscitation

Abstract

SynopsisSepsis is a common and life-threatening inflammatory response to severe infection treated with antibiotics and fluid resuscitation. Despite the central role of intravenous fluid in sepsis management, fundamental questions regarding "which fluid" and "in what amount" remain unanswered. Recent advances in understanding the physiologic response to fluid administration, as well as large clinical studies examining resuscitation strategies, fluid balance after resuscitation, colloid versus crystalloid solutions, and high-versus low-chloride crystalloids, inform the current approach to sepsis fluid management and suggest areas for future research.Keywords fluid resuscitation; sepsis; crystalloids; colloids; albumin; Early Goal Directed Therapy IntroductionSepsis is an inflammatory response to severe infection characterized by hypovolemia and vasodilation and treated with early antibiotics and fluid resuscitation 1 . In the United States, sepsis with organ dysfunction (severe sepsis) or fluid-resistant hypotension (septic shock) account for 2% of hospital admissions and 10% of intensive care unit (ICU) admissions 1 . Inhospital mortality rates have decreased from 80% in the early years of intensive care to 20-30% in the modern era 2-4 through improved surveillance, early treatment of underlying infection, and advances in support for failing organs. Despite the central role intravenous (IV) fluid administration has played in sepsis management for the last 15 years 5,6 , Corresponding Author: Matthew W. Semler, MD, Division of Allergy, Pulmonary, and Critical Care Medicine, Vanderbilt University Medical Center, Medical Center North, T-1218, Nashville, TN 37232-2650 Fax: (615) Publisher's Disclaimer: This is a PDF file of an unedited manuscript that has been accepted for publication. As a service to our customers we are providing this early version of the manuscript. The manuscript will undergo copyediting, typesetting, and review of the resulting proof before it is published in its final citable form. Please note that during the production process errors may be discovered which could affect the content, and all legal disclaimers that apply to the journal pertain. HHS Public Access Physiology of Fluid Resuscitation in SepsisPatients with early sepsis are frequently hypovolemic from decreased intake and increased insensible losses. In addition, inflammation alters vascular resistance, venous capacitance, and vascular leak generating a "relative hypovolemia". Resultant decreases in stroke volume and cardiac output imbalance oxygen delivery and demand, precipitating tissue hypoxia, anaerobic metabolism, and lactic acidosis.The classic physiologic rationale for fluid resuscitation in sepsis is to restore intravascular volume, cardiac output, and oxygen delivery. Volume and choice of resuscitation fluids have largely been predicated on this model. Resuscitation endpoints like central venous pressure (CVP), inferior vena cava filling, mixed venous oxygen saturation, and lactate are used to restore preload independen...

Utility of SOFA score, management and outcomes of sepsis in Southeast Asia: a multinational multicenter prospective observational study

“…Optimal fluid management of patients with sepsis in high-resource settings remains debated [ 27 ]. Intravenous fluid resuscitation in this study was generally restrictive.…”

Measuring and Managing Fluid Overload in Pediatric Intensive Care Unit

“…Colloid is a fluid containing macromolecules with the usefulness of increasing the oncotic pressure and maintaining the amount of fluid that already exists in the vascular and even absorb fluid in extracellular to intracellular [5,8]. Colloids are classified according to natural (albumin) and artificial (gelatin, dextran, and hydroxyethyl starch (HES)) [7].…”

“…Flori also suggested that fluid overload itself may be a risk factor for mortality regardless of initial presenting severity of illness [2]. In another study involving 778 patients with septic shock post resuscitation also found that fluid overload increased up to twice the mortality rate [5]. Vincent et al [7] in their research on sepsis patients found that each addition of a positive fluid balance after 72 h was associated with an increased odds ratio of mortality by 10%.…”

“…Many evidences have stated that excessive fluid administration is closely associated with negative effects for children who were admitted in PICU [3,4]. FO was known to cause increased risk of morbidity, mortality, additional time of mechanical ventilation, additional hospitalization time, and increased need for renal replacement therapy (RRT) [5,6].…”

Hotspot Analysis of Sepsis Literature

“…All the research directions are related to the fundamental purpose of treatment. To date, research into sepsis and its treatment has mainly focused on the following aspects: the pathology and physiology mechanisms of sepsis [ 5 , 6 ], studies involving animal models of sepsis [ 7 , 8 ], antibiotics treatments [ 9 – 11 ], fluid resuscitation therapies [ 12 , 13 ], shock treatments of sepsis [ 14 , 15 ], vasoactive medicine [ 16 , 17 ], prognosis of sepsis [ 18 – 20 ], prevention of sepsis, and epidemiologic studies [ 21 – 23 ]. However, disappointingly, the underlying pathogenesis of sepsis is not yet clear, but it involves complex systemic inflammatory network effects, genetic polymorphisms, immune dysfunction, coagulation disorders, tissue damage, and abnormal host responses to pathogenic microorganisms and their toxins from different infections.…”